AACN News—August 2003—Practice

Vol. 20, No. 8, AUGUST 2003

Public Policy UpdateBill Would Provide Grants for Associate
Degree ProgramsRecently introduced legislation would
establish a grant program for associate degree nursing programs to recruit
students, provide scholarships and hire faculty. Introduced by Rep. Michael
Capuano (D-Mass.), the Nurse Education Promotion Act (HR 2053) would also create
a competitive grant program for professional nurses' associations to conduct
continuing education programs in cooperation with hospitals and institutions of
higher education, which would enable associate degree nurses to take college
credit courses toward a bachelor of science degree in nursing. The intent would
be to make it possible for students to receive affordable nursing education
through the community college system. The bill was referred to the House Energy
and Commerce and the Subcommittee on Health.

AACN has endorsed this bill and encourages
members to contact their legislators to ask them to sign on as co-sponsors.

California Releases Final Staffing
RatiosThe California Department of Health
Services has released the final regulations to establish new minimum RN staffing
ratios that all California hospitals must meet by Jan. 1, 2004. In the package
approved by Gov. Gray Davis and the Department of Health Services, state
officials made critical decisions on some hotly contested issues regarding
implementation of the California Nurse Association-sponsored law. The law, the
first of its kind in the nation, has been a model for RNs and legislators in
other states. Following are some of the key decisions in the plan:

� Proposals by the hospital industry to
erode the ratios in emergency departments and postsurgical recovery units and
for evening, night and weekend shifts were rejected. State officials also
rebuffed hospital efforts to further delay implementation.� Improved nurse-to-patient ratios will be
phased into three hospital areas. As of 2008, ratios will be lowered in
step-down units, which typically house patients transferred from critical or
intensive care units; telemetry units, where patients are connected to monitors;
and other specialty care units, such as oncology and rehabilitation.� Hospital adherence to scope of practice
laws that protect patient safety will be ensured. No RN may be assigned or be
responsible for more patients than the specified ratios. In addition to
clarifying the respective roles of RNs and licensed vocational nurses and the
fact that the two are not interchangeable, the regulations require that
additional nurses be assigned as needed, according to the severity of patient
illness.� Hospitals are required to document
staffing assignments, including the licensure of the direct caregiver for every
patient in every unit on every shift, and to keep the records for one year,
which will help the state monitor and ensure compliance with the law.

In addition, another bill to help ensure
compliance has been introduced. AB 253 authorizes state health officials to
conduct unannounced inspections and provides for fines of up to $5,000 a day for
hospitals that continue to maintain unsafe RN staffing after final
implementation of the ratio law.

AACN addresses its position on staffing in
a statement titled "Maintaining Patient-Focused Care in an Environment of
Nursing Staff Shortages and Financial Constraints." This statement can be found
online.

Massachusetts Considers Minimum Staffing
Law Massachusetts would join California in
establishing a minimum nurse-to-patient ratio under a bill introduced in that
state's legislature. Backed by the Massachusetts Nurses Association, the bill
seeks a ratio of one nurse for every four patients in medical-surgical units and
a ratio ranging from between 1 to 1 and 1 to 3 in emergency departments,
depending on the severity of patients' conditions. In addition, the measure
would require the state health department to create a patient classification
system based on acuity to allow staffing flexibility yet account for patients
who require more care. The bill was introduced by state Rep. Christine Canavan
(D-Brockton).

Congressional Panels OK Funding BillsU.S. House of Representatives and Senate
panels recently cleared two huge bills funding labor, health and education
programs next year, despite reservations by both Republicans and Democrats about
the tight budgets they had to work with. The labor, health and education bill is
the largest of the 13 spending measures Congress must pass each year to fund the
government.

The House Appropriations Committee, which
oversees federal spending, voted 33-23 along party lines to approve the $138
billion measure, an increase of about 3%. The measure now moves on to the full
House. Earlier, a Senate Appropriations subcommittee voted 11-3 to send its
smaller, $137.6 billion companion bill to the full committee for consideration.

In other action, the House and Senate each
passed the most sweeping Medicare reform legislation since the program's
enactment. The House voted 216-215 for a 10-year, $400 billion prescription drug
and Medicare modernization bill. The margin in the Senate was wider, with 76
senators voting in favor and 21 voting against.

The bills now head to a House-Senate
conference committee to resolve differences. Both bills would provide billions
of dollars in payment assistance to rural providers but differ in their
treatment of hospitals and physicians. Under the House bill, hospitals would
receive a payment update below inflation through 2006; physicians would be
spared a rate cut scheduled for next year and see rates rise 1.5% in 2004 and
2005. Neither provision is in the Senate bill, but lobbyists expect the
conference committee to retain them in some form. House Speaker Dennis Hastert
(R-Ill.) said the House bill would reduce seniors' average individual drug costs
by 37%.

Bill Would Expand Access to Nurse
PractitionersU.S. Rep. John W. Olver (D-Mass.) recently
introduced the Medicaid Nursing Incentive Act of 2003 (HR 2295) to restore a
previous federal mandate to cover the primary care services of pediatric nurse
practitioners, family nurse practitioners and certified nurse midwives. The
mandate was eliminated by the Balanced Budget Act of 1997, which encouraged
states to move Medicaid recipients into managed care but excluded advanced
practice RNs as participants. The legislation would expand patient access to
quality healthcare by requiring states to offer Medicaid coverage of primary
healthcare services provided by APRNs and would eliminate the current option
that state Medicaid plans have to deny APRNs as primary care case managers.

Medicaid plans in many states currently
recognize only physicians for coverage. The proposed measure would help to
control Medicaid spending by offering Medicaid beneficiaries more and often less
expensive primary-care provider options. In introducing the legislation, Olver
noted that it would particularly benefit rural and other medically underserved
areas where nurse practitioners are often more accessible than physicians. The
bill also proposes to expand Medicaid fee-for-service coverage to include direct
reimbursement for all nurse practitioners and clinical nurse specialists,
instead of only the family practitioners, pediatric practitioners and midwives
currently covered. In addition, Medicaid-managed care panels would be required
to recognize the specialized services of select APRNs, such as the pain
management services provided by nurse anesthetists and mental health services
provided by clinical nurse specialists-thus clarifying the scope of providers
required by managed care plans to specifically include APRNs.

AACN has endorsed this legislation and
applauds Olver for introducing this bill supporting the practice of APRNs and
helping to ensure that Medicaid patients receive quality care in a timely,
cost-efficient manner.

Healthcare Leaders Set Course for
Environmental Health OutreachMore than 100 leaders in medicine, nursing
and environmental health have set a course for action to achieve a national,
interdisciplinary vision for environmental health outreach to healthcare
providers. The plan is part of the National Environmental Education & Training
Foundation's 10-year National Strategies for Health Care Providers: Pesticides
Initiative.

At a recent national forum in Washington,
D.C,. participants identified strategies and specific action items to expand the
emerging nationwide network of healthcare providers committed to incorporating
environmental health into primary care education and practice.

In addition, participants identified
opportunities to expand existing provider resources on the topic. In particular,
commitments were obtained from several individuals to seek endorsements by
national professional associations of the initiative's companion documents
"National Pesticide Competency Guidelines for Medical & Nursing Education" and
"National Pesticide Practice Skills Guidelines for Medical & Nursing Practice."
Additional action items included pursuing consumer-based promotion of
environmental health and pesticides messaging in tandem with primary healthcare
provider continuing education; initiating discussion and coverage of the issue
with leading physician and nursing societies; and creating educational
opportunities through credentialing bodies and professional societies that
influence providers' continuing education. A conference report is scheduled to
be available in fall 2003.

AACN has endorsed the National Strategies
for Health Care Providers: Pesticides Initiative implementation plan and
supports the call for primary healthcare providers to acquire basic knowledge of
the health effects of pesticides and the treatments and preventive public health
strategies to address them.

Study Finds Positive Results of
Emergency DefibrillationThe immediate use of defibrillators to
treat people in a heart crisis does more than save lives, according to a study
published in the June 26, 2003, issue of the New England Journal of Medicine.
The findings demonstrate that early, effective response to sudden cardiac arrest
by defibrillation and cardiopulmonary resuscitation results in an excellent
long-term outcome, including normal function and return to work.

Researchers tracked 200 people who had
received emergency defibrillation. Of those, 142 survived long enough to be
admitted to the emergency department, and 79 were eventually discharged from the
hospital. The five-year survival rate for those 79 people was identical to that
of the general population. A quality-of-life questionnaire given to 50 of them
produced answers typical of healthy people their age, the study said. Some
complained of persistent feelings of weariness, but most were back at work. In
fact, 65% of the survivors younger than 65 were working, the study found.Roger D. White, MD, professor of
anesthesiology at the Mayo Clinic, Rochester, Minn., was the report's lead
author.

In a related finding, a new poll found that
only 6% of U.S. workplaces surveyed were equipped with portable defibrillators.
Conducted by RoperASW and Philips, the poll also found that 53% of workplaces
that currently have portable defibrillators said they'd recommend that other
companies have portable defibrillators on site.

AACN supports the recommendations of the
American Heart Association on early defibrillation and public access.

Public Policy Snapshot

AACN Advocacy Efforts

AACN has recently submitted comments to
federal agencies on several important issues:

Department of LaborAACN joined other specialty nursing
organizations in delivering comments to the Department of Labor on proposed
changes to the Fair Labor Standards Act regarding the regulations that determine
overtime pay exemptions. AACN is concerned that the proposed changes will
eliminate the right to overtime pay for many nurses and has asked for an
extension on the deadline for filing comments on the proposals so that the
changes can be more thoroughly analyzed by the nursing community.

Department of Health and Human ServicesAs 2002-03 AACN president, Connie Barden,
RN, MSN, CCNS, CCRN, was contacted by Howard Zucker, deputy assistant secretary
for health, U.S. Department of Health and Human Services, and asked to comment
on the issues surrounding an unexpected sudden increased demand in the need for
critical care services across the nation.

Food and Drug AdministrationRebecca Long, RN, MS, CCRN, CNS, a past
member of the AACN Board of Directors, prepared comments on behalf of AACN for
the FDA regarding the proposed Bar Code Label Rules.

AACN's statements on these issues can be
read online.

Public Policy Information Online

The Commonwealth Fund has assembled
information highlighting recent research and analytical findings on Medicare,
including an overview of prescription drug benefit designs under consideration
by Congress.

For more information about these and other
issues, visit the AACN Web site at
http://www.aacn.org > Public
Policy.

Workplace Violence Focus of
Stakeholders MeetingAACN President-elect Kathleen McCauley, RN,
PhD, CS, FAAN, recently represented AACN at a healthcare stakeholders meeting on
the Workplace Violence Research and Prevention Initiative of the Centers for
Disease Control and Prevention-National Institute for Occupational Safety and
Health.

Discussion topics included the impact
workplace violence has on the nursing shortage and staffing, underreporting of
workplace violence, research on intervention strategies, cost-effectiveness of
prevention, and linking violence prevention to accreditation by the Joint
Commission on Accreditation of Healthcare Organizations. Of particular
importance was interest by the National Institute for Occupational and Safety
and Health in accessing and partnering with healthcare facilities and services
to collect data.

Practice Resource NetworkQ: We are in the process of reviewing and revising
our patient care standards for critical and progressive care. What is the
frequency standard regarding patient assessment and reassessment, including
vital signs?

A:
AACN does not have a standard for frequency of patient assessment. According to
the Standards for Acute and Critical Care Nursing Practice, the priority of data
collection is driven by the patient's immediate condition and anticipated
needs.1 The 2003 standards of the Joint Commission on the Accreditation of
Healthcare Organizations state that patient assessment should be completed
within 24 hours of admission, and reassessment should be carried out at regular
intervals thereafter.2 The reassessment intervals should be determined by the
patient's condition and hospital policy.2 There is no research to definitively
state what the minimum frequency interval should be.

When determining the hospital standard
regarding patient reassessment, acuity should be the major consideration. You
can also survey similar hospitals in your area to determine the community
standard. Acuity of patients may vary from unit to unit or even within the same
unit. Several different methods of developing hospital patient care standards
for critical care and progressive care units can be used to address the
differences in acuity. Minimum frequency regarding patient reassessment can be
addressed in specific unit-based standards, preprinted physician orders for
specific patient populations, disease-based protocols or clinical care pathways.

Remember that the standard you develop
represents the minimum level of care that should be delivered. Critical care and
progressive care nurses should always increase the level of monitoring based on
a change in the patient's condition or in specific treatment interventions that
may precipitate a change in condition. However, the level of monitoring should
never be less than what has been established as hospital policy. It is the
established minimum level to which nurses and the hospital will be held by
regulatory agencies and courts of law.

AACN, ENA Cosponsored Study Finds
Hospitals Still Limit Family Access to Patients During Emergency ProceduresDespite growing support for allowing family
members to be present during emergency medical procedures, only 5% of U.S.
hospitals have written policies permitting such access during CPR or invasive
procedures, according to a new survey of nurses cosponsored by AACN and the
Emergency Nurses Association.

In addition, despite guidelines to the
contrary, approximately one-fourth of responding nurses say family presence
continues to be prohibited during both resuscitation and invasive procedures.

The survey findings were reported in the
May 2003 issue of the American Journal of Critical Care and in the June 2003
issue of the Journal of Emergency Nursing.

"When patients are in literally a
life-or-death situation, their loved ones should be with them whenever
possible," said AACN President Dorrie Fontaine, RN, DNSc, FAAN, one of the
study's coauthors and associate dean for academic programs at the University of
California at San Francisco School of Nursing. "Having family present during
emergency procedures can be a great source of comfort and support for patients."

"A decade of research shows that the
presence of family members during invasive emergency procedures can be helpful
to families, healthcare providers and the patients themselves," added Kathy
Robinson, RN, ENA president and manager of the EMS Program for the Pennsylvania
Department of Health. "Yet, despite growing support for family presence during
emergency procedures, too many physicians and other healthcare practitioners
resist adopting this practice."

Among the findings of the survey, which was
sent to members of both AACN and ENA, are:

� Approximately one-fourth of nurses
reported that family presence was prohibited during CPR (29%) and invasive
procedures (25%), even though their units had no written policies prohibiting
such access.� 5% of the respondents worked in units
that had written policies allowing such access.� Family members ask to be present for such
procedures approximately one-third to two-thirds of the time (31% during
resuscitation, 61% during invasive procedures).� Approximately half of the units covered
by the survey allow family presence without a written policy (45% during
resuscitation and 51% during invasive procedures)."The option should exist in all hospitals
backed up by a written policy," Fontaine said. "There also should be education
so staff members can effectively support families in deciding whether to be
present during emergency procedures or resuscitation. An ongoing follow-up
mechanism should evaluate the effectiveness of the policy and ensure that the
rights of patients and their families are always respected."

Robinson agreed, saying, "Many ED managers
and hospital administrators may not be aware of the research that has been done
on family presence. Also, many may not know how to use the findings to develop
guidelines and policies, customize a staff education program, or how to
successfully facilitate family presence practices. Families are much more
resilient under these circumstances than many healthcare providers think.
Anticipated problems during resuscitation in hospitals that adopt this practice
have not materialized and, in fact, most times it helps families realize that
�everything possible was done' to save their loved ones."

Among the benefits the previous studies
have found for allowing families to be present during medical emergencies are:

� Removing doubts about what is happening
to the patient� Reducing anxiety and fear� Providing feelings of support and help to
the patient� Sustaining patient-family connectedness� Providing a sense of closure on a life
shared together� Facilitating the grief process� Engendering feelings of being helpful to
the healthcare staff

Fontaine said the nation's critical care
nurses, who are the most continually and intimately involved with seriously ill
patients and their families, should work closely with physicians and healthcare
administrators to adopt more widespread policies supporting family access during
emergency procedures.

"It is the responsibility, if not duty, of
every hospital to make the option of family presence available to those who will
find benefit from the practice," Fontaine said.

Sepsis Education Program AvailableIdentification and Management of
the Patient With Severe Sepsis," AACN's national sepsis education program for
nurses, is now available in a self-paced CD-ROM format. Funded by an
unrestricted educational grant from Eli Lilly and Company, this program is
sponsored by AACN and is accredited for 5.0 contact hours of CE credit for
single users.

Narrated by clinical expert Barbara McLean,
RN, MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive
view of the latest information on the diagnosis and care of patients with severe
sepsis.

The 170-page, audio/slide CD-ROM study
guide includes pathophysiology of severe sepsis; identification of acute organ
system dysfunction; antibiotics, source control and monitoring in severe sepsis,
including investigational and newly approved therapies; hemodynamic, ventilatory,
renal and other aspects of care; and nursing care of patients with severe
sepsis. Case studies are also included in the presentation.

To order this cutting-edge learning program
for only the $7.50 shipping and handling fee, call (800) 899-2226 and request
Item #004060. Quantities are limited.

Sept. 1 Deadline to Submit NTI
Research or Creative Solutions Poster Abstracts for 2004AACN is inviting research and creative
solutions poster abstracts for consideration for AACN's 2004 National Teaching
Institute and Critical Care Exposition in Orlando, Fla.

In addition to the posters, four awards
will be presented for oral research abstracts reflecting outstanding original
research, replication research or research utilization. Each of these awards
provides an additional $1,000 toward NTI expenses.

Sept. 1 is the deadline to submit the
abstracts.

The application as well as guidelines and
resources are now available online.

GrantsEvidence-Based Clinical Practice GrantThis program provides awards of $1,000 to
stimulate the use of patient-focused data or previously generated research
findings to develop, implement and evaluate changes in acute and critical care
nursing practice. Grant proposals are accepted twice a year and must be received
by either March 1 or Oct. 1.

AACN Clinical Practice GrantThis $6,000 grant supports research that is
focused on one or more of AACN's clinical research priorities.Oct. 1 is the annual application deadline
for this grant.

AACN-Sigma Theta Tau Critical Care GrantThis $10,000 grant is cosponsored by AACN
and Sigma Theta Tau International. The grant may be used to fund research for an
academic degree.Oct. 1 is the annual application deadline
for this grant.

To find out more about AACN's research
priorities and grant opportunities, visit the AACN Web site. The grants handbook
is also available from AACN Fax on Demand at (800) 222-6329. Request Document
#1013.

AACN Online Quick Poll

If your patient has a triple lumen catheter
and you are setting up to monitor CVP, which port is the most appropriate to
use?

Proximal 24%Distal 71%Medial 5%

Number of Responses: 1155

The AACN Online Quick Poll is a voluntary
survey on a variety of topics and is not scientifically projectable to any other
population. AACN presents these surveys to give our users an opportunity to
share their practice and opinions on particular topics. Participate by visiting
the AACN Web site.